2020 Connected Care (HMO) for San Joaquin County

The following benefit highlight information is for enrollment effective January 1, 2020. You’ll find many $0 benefits, as well as prescription gap coverage, health and wellness programs – and much more.


2020 Benefits Golden State Medicare Gold (HMO) WHAT YOU SHOULD KNOW
Monthly Plan Premium* $78.10 You must continue to pay your Medicare Part B premium
Deductible (Medical) $0 This plan does not have a deductible.
Maximum Out-of-Pocket (MOOP) $3000 The most you pay for copays and coinsurance for  Medicare-Covered medical services for the year.
Inpatient Hospitalization $150/day  1-5
$0/day  6-90
Our plan covers an unlimited number of days for inpatient hospital stay. Prior Authorization rules apply.
Outpatient Surgery
Ambulatory Surgical Center/Hospital
$100
$0
Prior Authorization is required for outpatient hospital services.
PCP Office Visit $0
Specialty Office Visit $10 Prior Authorization is required for specialist visits.
Preventive Care $0 Any additional preventive services approved by Medicare during the contract year will be covered. Prior Authorization rules apply.
Emergency Room $100, waived if admitted The emergency room copay will be waived if you are immediately admitted to the hospital.
Urgent Care $0 copay You are covered for worldwide urgent care services.
Worldwide Coverage Max Amount $100 copay/ $25,000 max Our plan covers supplemental world-wide urgent and emergency services outside the U.S. and its territories for a copay with a $25,000 plan coverage limit.
Diagnostic Radiology (CT, MRI, PET) $50 Prior authorization is required for diagnostic, lab and imaging services.
Lab Services $0 Prior authorization is required for diagnostic, lab and imaging services.
Diagnostic tests and procedures $0 Prior authorization is required for diagnostic, lab and imaging services.
Outpatient X-rays $50 Prior authorization is required for diagnostic, lab and imaging services.
Routine Hearing Exam $0/year Prior Authorization is required for Medicare-covered diagnostic hearing exams.
Hearing Aids $400 every 2 years (Reimbursement) Our plan pays up to $400 every two years for hearing aids.
Dental Coverage Office visit $8 Preventive Dental Care Plan offers additional comprehensive benefits..
Routine eye exam $0/year Prior authorization is required for routine eye exams.
Contacts and Eyeglasses $150 limit for eyewear every 2 years Our plan pays up to $150 every two years for contact lenses and eyeglasses (frames and lenses).
Mental Health Services $15 for Medicare-covered Individual and Group Sessions Prior Authorization is required for Medicare-covered Individual and Group Sessions. Referral is required for non-physician mental health specialty services.
Skilled Nursing Facility $0/(Days 1-20)
$50/(Days 21-100)
Prior Authorization is required for skilled nursing facility services. You are covered for up to 100 days per benefit period. No prior hospital stay is required.
Physical Therapy Services $0 copay Prior Authorization and referral are required for Physical Therapy and Speech-language Pathology Services.
Ambulance $200
Transportation $0 (48 one-way) 30 miles 48 one-way trip(s) within 30 miles to plan-approved location every year. Transportation can only be used for health-related visits.
Part B Drugs 20% Prior authorization rules apply to select drugs.
Part D Deductible $0
Initial Coverage Limit (ICL) $4020 Initial Coverage Limit is $4,020. Cost-sharing may change depending on the pharmacy you choose and when you enter another phase of the Part D benefit. For more information on the additional pharmacy-specific cost-sharing and the phases of the benefit, please call us or access our Evidence of Coverage online.
Tier 1: Preferred Generic
Standard Retail (31)
Standard Retail (90)
Standard Mail Order (90)

$5
$15
$0
Tier 2: Generic
Standard Retail (31)
Standard Retail (90)
Standard Mail Order (90)

$10
$30
$0
Tier 3: Preferred Brand
Standard Retail (31)
Standard Retail (90)
Standard Mail Order (90)

$45
$135
$90
Tier 4: Non-Preferred Brand
Standard Retail (31)
Standard Retail (90)
Standard Mail Order (90)

$95
$285
$190
Tier 5: Specialty Tier
Standard Retail (31)
Standard Retail (90)
Standard Mail Order (90)

33%
33%
33%
RX Coverage Gap Tier 1 & Tier 2, Some Rx in Tiers 3, 4 & 5 The coverage gap begins after your total yearly drug cost reaches $4,020. Full gap coverage for drugs in Tiers 1 & 2. For Tiers 3, 4, and 5 there is gap coverage on certain drugs. For drugs without gap coverage, after your total drug costs reach $4,020, you will pay no more than 25% copay for generic and 25% for brand-name drugs (plus a dispensing fee).
Catastrophic Coverage Limit $6350 Catastrophic Coverage Limit is $6,350. Catastrophic coverage begins after your total yearly drug cost reaches $6,350. During this stage, the plan will pay most of the cost of your drugs for the rest of the calendar year (through December 31, 2020).
Durable Medical Equipment/DME (wheelchairs, oxygen, etc.) 0% Under $500 , 20% $500 or more
Prosthetics (braces, artificial limbs) 0% Under $500 , 20% $500 or more
Diabetic Supplies $0 Auth Required
Fitness Program Silver and Fit
Over-the-Counter (OTC) $80 Every 3 months
OPTIONAL SUPPLEMENTAL BENEFITS and EXTRAS Acupuncture $10 Copay 12 visits per year, requires Authorization
MEDICAL GROUPS/IPA'S Medicare Medical Group/Omni IPA
Qualifying Chronic Conditions
Star Rating 2019

*You must continue to pay your Medicare Part B premium

*People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay for up to seventy-five (75) percent or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048.
For more information about Low Income Subsidy with Golden State Medicare Health Plan,  click here

Individuals must have both Part A and Part B to enroll in the plan.

You must use plan providers except in emergent or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers neither Medicare nor Golden State Medicare Health Plan will be responsible for the costs.

In general, beneficiaries must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances, and quanitity limitations and restriction may apply.

Members must receive all routine care from plan providers.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, co-payments, and restrictions may apply. Benefits, premiums, co-payments and co-insurance may change on January 1 of each year.

Last Update : 12/27/2019